Wednesday, September 02, 2009

British Heart attack patients denied lifesaving drugs

Thousands of women and older people are dying unnecessarily because they are denied proper treatment after a heart attack, claim British researchers. Doctors are failing to prescribe a full range of medication to one in five heart attack survivors which raises their risk of death within a year by 50 per cent. Data shows women and those over 60 are least likely to be given aspirin, statin and two blood pressure drugs that improve the chances of long-term survival.

The data was collated by the UK Myocardial Infarction National Audit Project which recorded the progress of 60,328 patients discharged from hospital after a heart attack between 2004 and 2005 In England and Wales. It is estimated that 2,000 deaths over a two-year period could have been avoided.

Experts suspect outdated ideas about heart problems being a ' man's disease' are partly responsible. But NHS guidelines insist there should be no discrimination.

The data was presented yesterday at the European Society of Cardiology meeting in Barcelona. Professor Iain Squire, professor of cardiovascular medicine at Leicester University, said: ' Irrespective of age and gender physicians should be trying to get all four drugs into these patients.'

In the UK in 2007 100,000 women and 93,000 men died of heart disease.


Seriously ill child dies after repeated NHS fob-offs and negligence

Even when he got to the stage above, NHS doctors just prescribed antibiotics

Ricardo Alves-Nunes spotted the tell-tale signs of chickenpox on his five-year-old son Fabio's face as he got him ready for school. 'Fabio was full of beans, just like he was on any other day, so I wasn't too worried about the three red spots on his cheeks,' says Ricardo, 37. 'Like most parents, we thought it was a good idea for him to have chickenpox young and get it over with. We both knew it could be a lot more serious for an adult. We kept him off school and waited for more spots to appear.

'My wife, Anna, phoned the GP to check if she needed to bring him in, but the receptionist told her it wasn't necessary. I'm from Madeira originally and Anna is Polish, and we've always had high regard for the NHS and trusted their advice.'

Little did the family know that Fabio would be among the one-in-100 chickenpox patients who suffer complications from the virus - and that three weeks later he would be dead. Around 95 per cent of children catch chickenpox before the age of 16, and for most it's a mild illness leading to itching, blisters and sometimes a high temperature. It's caused by the varicella-zoster virus and is highly contagious, usually lasting a week to ten days.

In an estimated one per cent of cases, though, serious complications can develop such as pneumonia, meningitis, encephalitis ( inflammation of the brain), inflammation of the heart and toxic shock, a type of blood poisoning - all usually down to impaired immunity.

Experts have calculated that complications may result in 6,700 children's hospital admissions a year in the UK. Indeed, there were 28 deaths from chickenpox in England and Wales in 2007, the latest figure available, including nine children.

Fabio's spots first appeared on February 7, 2008, but over the next few days Ricardo, a chef at a boarding school, and Anna, 36, from Redhill, Surrey, began to feel increasingly uneasy, despite being told a visit to the GP was unnecessary. 'Fabio had suffered from severe eczema outbreaks since he was a baby - he'd even seen the GP two weeks earlier because his skin had become so sore. The chickenpox spots just made it worse,' says Anna. 'As he scratched the blisters, they turned into sores and began to weep pus. He was extremely distressed, which was heartbreaking to see.'

By February 13, nearly a week after the first spots had appeared, Fabio was getting worse. Usually by this stage, the spots have begun to scab over and the worst is past. 'The doctor simply prescribed antibiotics and said I should carry on giving him Nurofen. I blame myself now that I didn't challenge the doctor'

Anna was so worried she phoned her GP surgery for a home visit. 'He had a high temperature and could barely open his eyes because they were so swollen,' recalls Anna tearfully. 'But the receptionist told me a home visit wasn't necessary and that I should give him a cool bath and some Calpol. At no point did she consult a doctor. 'I was upset, but didn't argue. All three of our children - Patrick, 12, Fabio and Olivia, who is now three - had been treated for severe eczema by the NHS and received good care. We had no reason to doubt them.'

But over the next 24 hours Fabio's condition worsened. Anna called the surgery again late in the afternoon. When she was referred to an outofhours service, she begged her brother, Jacek, to drive her to A&E at East Surrey Hospital a few minutes away. 'By this stage both Ricardo, who was home from work, and I knew Fabio needed urgent attention. The only time he stirred was when we touched him and that was because the pain woke him. 'I took a photograph of him before we left for hospital and thought I would be showing it to him when he'd got better to give him some idea of how ill he'd been. At the hospital, Fabio was so weak he had to be taken upstairs in a wheelchair.

'When I showed the doctor his open wounds I felt sure he would be admitted - if nothing else, I thought there must be a danger they could become badly infected. But the doctor simply prescribed antibiotics and said I should carry on giving him Nurofen. I blame myself now that I didn't challenge the doctor.

'The next three days were a nightmare. Fabio barely ate or drank and his skin was so raw and weeping that I had to change his pyjamas four times a day,' says Anna. 'Every morning his sheets were stained with blood.' 'But we trusted what the doctors had told us, so I never thought to take him back to hospital - of course, I see that was a mistake now.'

On February 17, Fabio began to lose consciousness. Ricardo says: 'I carried him downstairs and his head rolled back - I thought he was dying. I called 999, but they sent just one paramedic.' Although back-up was called, the crew were happy to leave Fabio at home and it was only on Ricardo's insistence that he was eventually taken to East Surrey Hospital.

'We spent three-and-a-half hours in A&E. When a doctor eventually came, I could see the shock and panic in his eyes. They couldn't even take any blood samples, as Fabio was so dehydrated,' says Ricardo. 'He was eventually admitted and I stayed with him while Anna looked after the other children at home. Fabio woke me several times that night asking for sips of water.

'When the nurses put bandages on, they used the type used on burns victims. No one gave us any indication that his life was in danger; we just thought: "Thank God he's finally getting treatment; he'll be OK now." ' But on February 18, Fabio's condition deteriorated and he was transferred by ambulance to the Evelina Children's Hospital in London. 'When we arrived, doctors warned us that he was very sick and might not survive,' Ricardo says. 'We were totally shocked. How could a skin infection have made him so ill that he was fighting for his life? Still, no one really explained what was wrong or what treatment they were going to give.'

It was only after Fabio's death that a post-mortem revealed he had developed toxic shock, a type of blood poisoning caused by the bacteria Staphylococcus aureus. A rare complication of chickenpox, the bacteria produces a poison which enters the bloodstream through a wound and can cause organ failure.

Fabio was given fluids and antibiotics and spent the next ten days on a respirator, which took over his breathing function and supported his organ function. He appeared to stabilise.

Anna's brother was now looking after the other children, who also had chickenpox (although less severely) so both Ricardo and Anna were able to stay with Fabio at the hospital. We talked to him and played CDs of his favourite songs and stories. He loved the Crazy Frog song and Winnie the Pooh; when we played them, he would squeeze our hands and move his head - he really wanted to live.' Sadly, it was too late; Fabio died on March 1 of multiple organ failure.

Seventeen months on and the couple remain devastated. Anna and Ricardo blame themselves - but feel staff at the GP surgery and East Surrey Hospital failed them. The family complained to the hospital after Fabio's death and had a meeting with officials, but it took until June this year to get a formal apology or explanation of the events that led to Fabio's death.

'A coroner's inquest found that Fabio died of natural causes, but how can it be "natural" for a child to die like Fabio did?' says Ricardo. 'For some reason, I wasn't allowed to give evidence at the inquest. I had a letter prepared about his eczema - but this wasn't discussed. It was as if they were saying it wasn't relevant.'

Now an independent investigation team, led by paediatric doctors and nurses from nearby Darent Valley Hospital, has published a damning 26-page report on what went wrong with Fabio's care at East Surrey Hospital. The report reveals a catalogue of 'missed opportunities' to treat the boy's condition earlier and more aggressively, poor communication between doctors and a culture where nurses said they felt unable to challenge medical opinion.

Names of staff are blacked out, but the report clearly states the care provided by three doctors at the hospital 'fell below the standard expected from a paediatric unit in a District General Hospital'.

Dr Gareth Tudor-Williams, reader in paediatric infectious diseases at Imperial College, London, says: 'It is easy to be wise after the event, but if a five-year-old child with chickenpox, a history of severe eczema and a heart rate of 164 presented to hospital, I would say unequivocally that he should be admitted and given acyclovir (an anti-viral treatment for chickenpox) intravenously.


Stupid, heartless and useless British paramedic

Mother-of-three died in pub as solo woman paramedic 'stood outside and refused to help'. But no doubt she was following "the rules"

A pub manager has demanded disciplinary action against a paramedic she claims would not help save a customer's life. Melissa Procter-Blain, 32, died after suffering a heart attack at The Crown in Spondon, Derbyshire. Her friends and family have told how the lone paramedic who responded to a 999 call first parked outside the wrong premises and then refused to enter the pub. They also claim the female paramedic refused to try to resuscitate the mother-of-three on her own and that one of the pub's customers had to step in instead until back-up arrived.

Landlady Michelle Doherty, 34, is now calling for the paramedic to be suspended while an investigation into the incident is conducted. She said: 'We were waiting outside for the ambulance and we saw the paramedic had parked outside a garage down the road. 'A young lad ran from the pub down to tell her she was in the wrong place but came back and said she wouldn't come in. 'My partner Kevin then ran down to talk to her and she said she wasn't authorised to go into a pub alone and would only come in if he could guarantee her safety, which he did.'

East Midlands Ambulance Service had logged the incident as a category A - potentially immediately life-threatening - and sent a fast-response vehicle, which arrived within six minutes, and an ambulance, which arrived within ten minutes.

A spokesman said the solo responder paramedic took the life-saving kit from her vehicle into the pub but had described the atmosphere as tense and intimidating. But witnesses in the pub dispute this claim. Ms Doherty said that while her partner spoke to the paramedic, one of her customers, Leanne Dono, was on the phone to a 999 operator. She claimed the controller told her the sole responder would begin trying to resuscitate Miss Procter-Blain.

Miss Dono said she then spoke to the paramedic, who said she was not authorised to carry out cardiopulmonary resuscitation (CPR) on her own.

Miss Dono said: 'I was talking to the 999 lady and she said I had to count Melissa's breaths. I counted one, then there was a long gap, then I counted another. By the time I got to the fifth breath, her face had turned grey and there was foam coming out of her mouth. I told the lady on the phone I thought she was dead. 'That was when the paramedic came. I told her that the 999 lady was saying she should try to resuscitate Melissa but she said she couldn't on her own, so my boyfriend Scott started doing CPR instead.

'It was horrible. Everyone was standing around and crying, but it wasn't threatening. Everyone was just really upset.' Pub manager Kevin Pearson, 35, said everyone had been disgusted by the actions of the paramedic. He said: 'We were begging her to come in and help but she just said she couldn't do anything on her own. What was the point in sending someone on ahead if they can't do anything once they get there? 'She wasted so much time, parking outside the wrong place, refusing to come in then not doing CPR. We don't know if Melissa's life could have been saved, but the paramedic could have at least tried.' Miss Procter-Blain was dead on arrival at Derby Royal Infirmary following the incident on July 12.

She had arrived at the pub with her family. She was in a wheelchair after an accident eight weeks before, when she fell over a doorstep, and was drinking soft drinks. She was in the pub's toilet with pal Hailey Bell when she suddenly lost consciousness. Miss Bell, 27, said: 'I was just opening the door when I heard this really horrible noise and when I looked at Melissa, her head had rolled back and she was looking up at the ceiling. 'Scott took her out into the pub and she seemed to be coming round, but then her head fell back again, which is when Leanne called the ambulance.'

Miss Procter-Blain's father John Page has met representatives of East Midland Ambulance Service (EMAS) to discuss his concerns. He said: 'I think paramedics do a great job but this woman just stood there are refused to treat my daughter. I think she should be struck off for what she did.'

An EMAS spokesman said it had launched an investigation immediately after receiving Mr Page's complaint letter. He said: 'Once we have completed our investigations, we will notify Mr and Mrs Page of the outcome. 'Until then, it would not be appropriate for us to make further comment about the case.'

Miss Procter-Blain's three children, aged 14, nine and four, are now being cared for by her father John and mother Diane.


Australian public health insurance system in a mess

Quick summary for non-Australian readers: Australia's Medicare is a government-run health insurance program that covers ALL Australians out of tax revenues. About 40% of Australians, however, want higher quality care than what Medicare will fund so take out private insurance and go to private hospitals. People with private insurance get a tax rebate in recognition of their reduced use of the public system

MEDICARE has been stretched to the point where it risks putting more into doctors' pockets than into care of the chronically ill. A major government-backed report has singled out poorly targeted payments for patient "care plans" as symptomatic of a primary health system fraying at the edges and in need of funding reform.

The long-awaited report into frontline healthcare, including GP services, was launched by Kevin Rudd and Health Minister Nicola Roxon yesterday with a promise to retain the Medicare Benefits Scheme at its core.

But the Primary Health Care Reform in Australia report warns that Canberra is expecting too much of Medicare by extending it beyond simple fee-for-service reimbursements to fund GP care plans for patients with complex, long-term health problems such as diabetes, heart disease and mental illness.

The costly expansion raised concerns that "the quality of care provided is unknown and that the objectives of co-ordination and continuity of care may not be being achieved", it said. Ten per cent of GPs, for example, claim 54 per cent of all Medicare items for chronic disease management care plans, leaving the program's impact across the population "open to question", the report noted. Payments to doctors for CDM care plans cost taxpayers $204million in 2007-08 alone.

A Medicare Australia audit found that more than one-third of care plan items claimed did not comply with MBS requirements.

The Professional Services Review, which investigates potential Medicare abuses, has also written to the federal Health Department about the risk the claims could be driven more by business than clinical imperatives, the report revealed. "In particular, the PSR is concerned that plans are being opportunistically generated, based on system-driven templates that do not reflect patients' actual needs and that are not necessarily shared with or even provided to the patient," it said.

In the May budget, the Rudd government used excessive doctors' fees as justification for cuts to reimbursements for IVF, obstetrics and cataract operations, claiming the most prolific 10 per cent of eye specialists earned $1m through Medicare last year.

The latest report opens the door to further payment reforms, breaking away from fee-for-service arrangements towards salaries, pay-for-performance or other incentives.

The centrality of GPs' role in patient care could also be eroded in favour of giving people more direct, affordable access to allied health workers, using pharmacies to assess risk factors, and workplaces to deliver healthy lifestyle programs. "There is widespread agreement that the Australian healthcare system, in common with many other countries, does not provide the highest quality care for the money spent," the report noted.

But AMA president Andrew Pesce warned that patients' health would suffer if they lacked a doctor to co-ordinate overall treatment. "Unfortunately, there are some danger signs in this draft strategy and in the National Health and Hospitals Reform Commission Report that the government is planning a lesser role for GPs under the guise of 'health workforce reform'," he said. "The AMA must oppose any diminution of the role of the GP in primary care, and so should the whole community."

The government will not, however, finalise the draft primary healthcare strategy released with the report until late this year at the earliest. Despite receiving the report a month ago, the government will defer decisions on which proposals it will pursue until it strikes agreement with state and territory governments on how Australia's future healthcare system will be funded.

Relations between the government and the AMA have been strained by sharp policy differences on issues ranging from GP super-clinics to budget cuts to private health insurance and the Medicare safety net.


Health care through central planning: A helpful analogy

Some wonderful analogies have been offered that sweetly damn the "Cash for Clunkers" idiocy. We can look at how this logic would extend to lousy houses that don’t "work" anymore, and the mainstream news is reporting a possible "Kitchen Clunkers" program to "stimulate" department and home supply stores, presumable complete with public spectacles of smashing refrigerators. For farmers, the latest buzz is a "Cash for Clunker Cow" program. "[T]here are vast differences in cow efficiency…So, how about providing, say a $200/cow subsidy to allow producers the opportunity to trade in our older, less-efficient models for more efficient, newer models?" writes Cow-Calf Weekly editor Troy Marshall. Of course, he is writing tongue in cheek, picking up on a joke that has been on the cattle circuit since the onset of the "Clunker" program.

Having the federal government buy or subsidize worthless assets (with borrowed or confiscated money) is not new. I remember the stories of the $500 hammers and $2000 toilets back in the day when it was popular to question military waste. And that’s parlor room stuff. In my lifetime, the wars pursued by the federal government, whether against drugs or countries or cultures have been classic case studies in obscene levels of federal spending, concomitant with physical destruction of people and property, for absolutely nothing. Afghanistan? Simply a "Cash for Clunkers" program on an international scale – this one targeted at sustaining US military contractors, subcontractors, and extended family members, as well as bumping up the military budget (think Government Motors, Rockets, Planes and Torpedoes, Inc). Iraq, on the other hand, could be viewed as government spending at extreme levels for non-operating and insecurable oil fields – and perhaps most significantly, on property that does not and will never belong to us! How Lehman Brothers! It all makes perfect and beautiful sense, in a "Cash for Clunkers" world.

The Bush buyouts were no surprise, nor should it be surprising that the insanity continues at home and abroad under Obama. After all, when you join a club, you do so because you like the way it does things and how it makes you feel, not because you want to make radical changes. Obama’s pledge of "Change!" was certainly a cruel joke on the masses of na├»ve believers in government who live, like picket-fenced housewives, in a world made substantial through dreams.

Let’s consider how all this will work in government-provided health care, whether you call it single payer, or just Article 99 writ large, or something in between. We already have several examples of government health care – and apparently the only one that people want to talk about is the Congressional insurance program, whereby millions of people subsidize the unlimited health care for an unaccountable few. Well, if you are the few, it’s a great program. But to hold this up as an example in town hall meetings is proof that a century of public schooling in this country has succeeded in producing a nation of parrots who can repeat words but have no idea, or apparently interest, in what those words mean.

The health care that the government already runs has also been mentioned. The real performance versus cost of the military hospital system, the abject hinterland of VA hospitals, and the contracted HMO memberships offered to the military families could be discussed. Less well known is the Indian Health Service, and its track record, described succinctly here in an article written by the executive director of the Property and Environment Research Center in Montana. It’s not rocket science – federal management of anything, even its bare-bones constitutionally chartered duties, is flawed at best.

But there is some good news about increased government ownership and direction of the health care system, presuming that’s the path we're on. It comes in small ways, and some might think, mysterious ways. For example, I have a government subsidized medical insurance. I’m not clear on what it provides or doesn’t provide, exactly, as in the six years since I retired, I have used it one time, in getting a school physical for my then high-school aged son. We found out, after we paid our part of the bill at the physician’s office, that they maintained one price for insurance, along with a cash price. Turned out .. drum roll… the cash price was actually cheaper than the deductible! So henceforth, we paid cash.

Of course, my family has in recent years, been healthy, and in the case of accidents, costs have been shared by responsible parties. My daughter crashed into something on the soccer field and had to have some MRI work done – our share for that ran close to $1000. One imagines how wonderful truly free market medicine would be, with real choice, and real competition in the industry.

We have examples – ophthalmology and veterinarian services come to mind first. You can get an eye exam for $50, and then order glasses online for another $20. Overall, that’s less than a pair of running shoes, or a meal out with the family at Applebee’s. The wide variety of eye surgeries available and the competitive and safe nature of these surgeries speak to the working of a freer market than what we see for the rest of our health care. The argument by the statist left and statist right is falsely premised by the idea that the current health care "system" is a free market system, and based on the ideas that free market systems can’t work for health care because people are not all equal in either health, desires for health or finances.

But the market works precisely and wonderfully because we are differently abled, financed, with unique wants and desires! It works well in animal health care (you can buy cheap medicines and health aids across state and international lines for your pets competitively and privately, and a whole new array of private insurance products have emerged to help you meet the unexpected health needs of Fido or Kitty). Compare this to our government controlled and manipulated system where buying your meds in Canada or Mexico, or self-medicating with THC will land you in jail.

But what happens in this private system when animals, for example, don’t get the heath care they need, due to poverty or ignorance? Private organizations – unfortunately often working with the state, as in the case of the SPCA, or working in extreme ways, as with PETA) do step in. More often than not, they are beaten to the punch by neighbors and concerned citizens who work far more quietly and lovingly. In the case of human poverty, innumerable private organizations run hospitals, providing clinics and eyeglasses, and even surgeries for the needy. Again, unseen, is the quiet and sustained help given by family members and friends when people are in dire straits. We don’t see this undercurrent on television or read about it in the news – but it is real.

The marketplace would do a wonderful job in providing organs and blood products, if unleashed from government control. Everything has value, including above all the health of human beings – and the most destitute among us can make a wish and have it granted by a free society and the innumerable charities a free society can support. For the rest of us, a little personal responsibility goes a very long way. It’s also the American way, if you ever watched an old Western, or one of Clint Eastwood’s more recent ones!

If we get more governmentized and centrally managed health care, one thing we can look forward to is even more waste and misallocation in the industry – and both of these eventually find a home in black and grey markets, which in turn foster increased distrust and delegitimization of government.

What Americans need is a helpful analogy, like "Cash for Clunkers," to help them think about the health care proposals being put forth by government and interested corporate beneficiaries. How about collective agriculture in the old Soviet Union and Eastern Europe? During the Cold War, we often heard about the incredibly productive backyard gardens of the downtrodden peasants, and the poor yields of the massive state fields. The uninformed among us credited this as an excellent example of incentive over command economies. But what we forgot then, briefly, is that, absent a true pricing system and real freedom, productivity and availability of goods will always be severely constrained overall.

In the 1980s assessment of backyard garden superproductivity of the old Soviet Union, agriculturalists, economists and pro-freedom advocates all missed a simple fundamental reality. This mythical small-garden "productivity" was wholly dependent on a concentration of work time, equipment, fertilizer, good seed, and actual meat, grain, fruits and vegetable products "stolen" from the "state" and subsequently sold on the "free market."

That this theft was justified to feed the people is beside the point. Collective and command driven health care will produce similar results – and ultimately we will begin to hate the healthy.


Comparative effectiveness research and junk science

By: Michael Barone

Employing comparative effectiveness research—determining which medical treatments are most effective—is one of the means the Obama administration says government can reduce health care spending. If government pays only for treatments that are most effective, the theory goes, then it will save money.

I’ve been skeptical about comparative effectiveness research. In my July 12 Examiner column, I wrote, “But comparative effectiveness research is, if not junk science, not a fully developed intellectual exercise. Medicine is an art as well as a science, and comparative effectiveness research may too often compare apples and oranges.” In response, an email correspondent wrote, “More generally, the entire concept of ‘comparative effectiveness’ goes against the cutting edge of biomedical research. Evidence mounts daily that humans are far more individualized biologically than previously believed. . . different ethnic groups, age cohorts respond to drugs in ways almost as marked as disparate genders. Comparative effectiveness testing given just those variables quickly becomes more expensive than any possible realized savings. In short, ‘comparative effectiveness’ is sloppy, shortcut thinking that ignores reality in an attempt to end debate, rather than struggle with the difficult question of how far we individuate treatment.”

Today in the Wall Street Journal we have testimony to the same effect from two individuals far more expert than me or my email correspondent—Dr. Jerome Groopman and Dr. Pamela Hartzband of the faculty of Harvard Medical School. Dr. Groopman is also a staff writer for the New Yorker. They write:
“But once we leave safety measures and emergency therapies where patients have scant say, what is ‘the right thing’? Data from clinical studies provide averages from populations and may not apply to individual patients. Clinical studies routinely exclude patients with more than one medical condition and often the elderly or people on multiple medications. Conclusions about what works and what doesn't work change much too quickly for policy makers to dictate clinical practice.

“An analysis from the Ottawa Health Research Institute published in the Annals of Internal Medicine in 2007 reveals how long it takes for conclusions derived from clinical studies about drugs, devices and procedures to become outdated. Within one year, 15 of 100 recommendations based on the "best evidence" had to be significantly reversed; within two years, 23 were reversed, and at 5 1/2 years, half were contradicted. Americans have witnessed these reversals firsthand as firm ‘expert’ recommendations about the benefits of estrogen replacement therapy for postmenopausal women, low fat diets for obesity, and tight control of blood sugar were overturned.”

The idea that we can standardize medical treatments, so that health care operates with the mass efficiency of an assembly line at one of the old Big Three auto company plants, seems to be a delusion. There’s a reason that most of us are not only not physicians, but not capable of becoming physicians. There’s a reason it takes four years for physicians to get their medical degrees and that they typically need four or more years of post-degree training after that. Comparative effectiveness research may very well be useful. But to standardize medical treatment on the basis of comparative effectiveness research seems like the height of folly.


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